Symptoms usually develop gradually and only manifest at a loss of more than 60% of pulmonary vasculature. Although dyspnoea (particularly breathlessness caused by activity) is a common early symptom, it is not a cardinal symptom. Fatigue, reduced performance, chest pain, recurring syncope on activity and after attacks of coughing, haemoptysis (which may occur with all forms of pulmonary hypertension) and dizziness are other symptoms.